Laserfiche WebLink
DILHIR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> -- . MEN Bur <br /> STATE SANITARY PERMIT#)-,))f;75 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ Cy 19�� <br /> 8%X 11 Inches In size. Check if rein to previous application <br /> -See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOC TION <br /> / r %J` '%, S T N, R E (or W <br /> PFIOPEPAY OWNER'S MAILING ADDRESS LOT# n BLOCK# <br /> ,Cux^lX OV -- <br /> CIN,STATE ZIP CODEPHONE NUMBER -y DI AME OR CSM MBER <br /> C/PJ //7e S1:1 ��p <br /> II. TYPE OF UILDIN : (Check one) ❑ State Owned p CITY ( L/a N� ES'T RO D/�' ) <br /> 1:1 Public tor2Fam. Dwelling,#ofbedrooms� EL TAX NUM E O GLC�� �Lw <br /> Ill. BUILDING USE: (If building type is public,check all that apply) :Z-9135- 05-�nO <br /> 1 ❑ ApVCondo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit# — Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER 1 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REOUIREq(�ft.) PROPO§D q.ft.) (Gals/day/sq.ft.) (Min./inch) LEV79TION <br /> ��77// / 3 Feet r Feet <br /> VII. TANK CAPACITY Site <br /> INFORMATION in allons Total #of Prefab. Fiber- Exper. <br /> New istin Gallons of Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdinct Tank <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature: Stamps) MP/MPRSW No.: Business Phone Number: <br /> iz "Wk <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 5a c. 16ff <br /> IX. COUNTY/DEPARTMENT USE ONLY Ej <br /> Disapproved Sanitary Permit Fee Psurcnerge Feej water e e e Iss ' gent Sign (No Stamps) <br /> Approved E3 Owner Given Initial p� <br /> AdverseDetermination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />